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Integrated Summary of Stakeholder Consultation - November 19, 2001
Introduction
The Minister of Health, the Honourable Julie Bettney, hosted seven Regional
Health Forums across Newfoundland and Labrador in the fall of 2001 for invited
representatives of health and community groups. The participants in each Health
Forum represented a range of health, municipal, educational, community, union,
and governmental organizations, as well as elected members of the House of Assembly.
The purpose of each Forum was to engage participants in an analysis of major
health issues. These issues included Health Services Structure, Health Care
Funding, Wellness Focus, Health Services Delivery Model, Health Human
Resources and Accountability. The feedback from the Regional Health Forums
is an important element in the November 2001 Provincial Round Table and is
a mechanism to reach consensus on critical health system issues. This report
is an integrated summary of the highlights of the forums and examines
opportunities that can be leveraged for an improved, sustainable health
system for the province.
Participants in the Regional Health Forums were assigned to one of six
groups to discuss of the questions posed in the discussion document entitled
Reaching Consensus and Planning Ahead. Where a group was able to reach consensus,
the members were also asked to articulate what, if any, conditions must be met to
maintain the consensus view. Where consensus was not reached, participants were
asked to consider what key issues were barriers. Finally, there was an
opportunity for participants to share other key observations and comments
regarding the six themes discussed throughout the day.
There was rich discussion, sharing of experience, and generation of ideas.
Many diverse views were expressed, some consensus was reached, and areas still
needing attention were identified. The process used and the resulting output from
group discussion were considered successful by participants, facilitators, and
sponsors.
The remainder of this document is a synopsis of the comments resulting from group
discussions. The feedback is organized according to the health care issue to which
it pertains - Health Services Structure, Health Care Funding, Wellness Focus, Health
Services Delivery Model, Health Human Resources, and Accountability.
Health Services Structure
Although diverse views were expressed with respect to health services structure,
there was acknowledgement that the number of boards could be decreased through greater
integration. Such integration could promote a more holistic view of health at the
board level, enable greater coordination of services, improve communication,
create many opportunities to capture efficiencies, better allocate resources,
offer seamless service delivery, and enhance client focus.
A strong sentiment was expressed that this may not be the right time to create
further disruption in the system, but there was an openness to continuously
examine and improve board structure. It was felt that an evaluation of existing
board structures is required, as well as an evaluation of the effectiveness of
integrated boards. There are no quick fixes, particularly when funding remains
a critical issue. Fiscal pressures should not be the exclusive rationale for
reducing the number of boards. Additionally, there should be no reduction in
funding to geographical areas. A reduction in the number of boards should not
be viewed as a financial saving.
Any move to reduce the number of boards must be taken cautiously, and be based
upon a thorough analysis of existing integrated boards, service and program
needs, and geographical and demographic characteristics. Proper implementation
planning must occur and include extensive stakeholder participation and a
communication plan to help employees, the public, and others understand what
change is occurring and the implications of this change. Additionally,
government must resolve the issue of downloading services and programs to
boards that are not adequately funded.
Participants felt that the complex nature of coastal, regional, and provincial
services does not make direct comparisons among regions possible, but that continued
emphasis should be placed on achieving a greater continuum of seamless care.
There was no overall consensus regarding methods for determining board membership.
Benefits and limitations of boards that are appointed, elected, or a combination of
both methods were identified. An appropriate combination of continuity and turnover
in membership, avoidance of single-issue boards, diverse skills and expertise, and
democratic processes for balanced community and regional representation were seen as
important critieria for board membership. It was also identified that there is a
need for orientation, education, as well as clarification of role, mandate, and
allegiance of board members. The need for greater transparency in how appointments
occur and how one volunteers was also highlighted.
Health Care Funding
There were varied opinions regarding the options for funding the health system but
the need was expressed for additional data on the proposed options. There was
widespread consensus that cost pressures in the health system should not be funded
through new taxes, government borrowing or reallocations from other Departments.
Some participants provided strong support for reallocation of resources within the
health care system if based upon a redefined system and government leadership. In
addition, participants felt the federal government should be pressed to contribute
a greater share of health funding. There was strong support for the principles of
the Canada Health Act. However, some reluctance was expressed regarding
privatization of health services and the introduction of user fees, even if
privately run services reportedly tend to be characterized as more efficient.
Concern was expressed regarding the potential disadvantage to vulnerable groups
within society.
Participants indicated that some services lend themselves to privatization, but
any decision to do so must be evidence-based and minimum standards for quality
must exist. Key considerations are the ability to monitor quality and the potential
to make health care technology more widely available. Possible options for
publicly-funded, privately-operated health services included such services as
facility management, laundry, food, laboratory, housekeeping, home care, long-term
care facilities, radiology, and physiotherapy.
A review of the system structure and funding model were regarded as necessary, taking
into account the following types of issues:
- Increased borrowing is not an option and never a solution; inefficiencies still
exist in the system;
- Health system leadership and the principle of accessibility are required
to make important decisions regarding what can and cannot be reduced, what basket
of services should be offered, and where these services should be located;
- Investments in information technology could make the health system more efficient;
Outcome measures must become more prevalent;
- There are long-term impacts for investing in health promotion and health
education in both the health and education systems;
- The system cannot sustain further funding cuts;
- Unions and professional associations must be part of decision-making regarding
where reallocation can occur;
- Government must take a leadership role in reviewing policies that may no longer
be serving the system well (e.g., liberal sick leave policies); and,
- There is a need for data, including comparative data for community health.
An integrated and well-funded health system is required, one that is based upon
good data, a balanced approach to social and health policy, and more creative and
flexible approaches to the delivery of health services.
Wellness Focus
A wellness focus was strongly endorsed with the observation that wellness is
dependent on many broad factors including employment availability, economic
development, improved public education, and cross-departmental and
community-level collaboration. There was a strong sentiment that intervention
and support must be available to all children and their families, and not targeted
to those identified as having needs. Personal health practices and coping skills
information were considered important tools. There was acknowledgement that we must
take responsibility for our own health, but to assist this government must support
community-based self-care groups by providing them with stable funding and resources.
Participants felt strongly that there is a need for awareness and education for
both health professionals and the public. Full utilization of skills and
expertise by health professionals such as licensed practical nurses and
practical nurses is needed, as well as, re-orientation of health
professionals from a treatment focus to one of prevention.
A holistic approach, using existing service delivery models with more
sharing and collaboration through community networks will be required to ensure
that these needs are met. It will also require aggressive marketing and promotion
of the wellness model, alternatives to standard treatments, physician fee
structures that support prevention activities, supports for community-based
initiatives, and training of community volunteers to support wellness work.
To help people and communities improve their health and well-being, various
suggestions were made including:
- Engage in meaningful dialogue with the public to ensure they are aware of health
system issues and myths;
- Continue efforts to ensure schools, communities, and health care professionals
have a wellness orientation;
- Help health care professionals and families model healthy practices;
- Move beyond rhetoric and into action;
- Recognize and use alternative forms of health care; and,
- Base decision-making upon best practices.
Health Services Delivery Model
Participants generally agreed that while there are no easy answers to how and where
health services should be delivered, the principles of accessibility, quality,
accountability and sustainability are the right ones for guiding the overall
approach to health services delivery. However, terms such as 'medically necessary,'
'reasonable access,' and 'core services' require greater clarification.
There was agreement that there must be reasonable access for all citizens
to primary health care services. Quality refers to standards of excellence
and performance, sensitive response to patient needs, and the availability of
appropriate professionals. This standard must be measured through the use of
benchmarks and performance indicators with a focus on continuously examining
successes and problems, and seeking improvements.
A number of considerations were identified for the development of standards
to guide service availability at local, regional and provincial levels. These
standards must consider critical mass of clientele to sustain specialty
services and professional competence, the availability and affordability
of transportation, and flexibility to respond to geographical and other unique
factors. The focus should be upon doing the right things for the right reasons
and using the appropriate resources with individuals being held accountable.
An accountability framework must be seen as being helpful rather than punitive
and address affordability. Boards require the autonomy to make tough
decisions that are aimed at sustaining the system. It must also be recognized
that the system cannot currently respond to public expectations.
To guide decision-making regarding the availability of services, consideration
should be given to community-based primary health care, articulation of
core services, clustering of services, the effective use of emerging
technology, timely and equitable access to primary, secondary, and
tertiary health care services, and alternate physician payment models.
Key features of primary health care teams is the ability to be
multidisciplinary and accessible, where all health professionals work as
equal, collegial partners to their full scope of practice with equal emphasis
on wellness and treatment. Significant barriers exist for an effective
primary health care delivery system. These include professionals who are
not working to their full scope of practice, a lack of trust between primary
health care team members, and a public that does not fully understand
the role of primary health care. There is also underdeveloped and underutilized
technology, difficulty in attracting and retaining the right configuration
of health professionals (especially in rural areas), and the time and commitment
required to engage in community development. Turf issues are perpetuated by
public expectations for the physician being the first point of contact and
physician remuneration models that do not adequately reward wellness work.
To overcome these barriers, creativity, innovation and leadership are required.
There must be adequate funding and budget flexibility, opportunities for staff
development, and a reorientation of professionals. It was noted there
are likely still 'sacred cows'. Change management teams are required to
support change initiatives and a careful study of the outcomes of the
Primary Health Care Enhancement Initiative is required to determine best
practices and lessons learned. We need to acknowledge and build on what
is working well.
Several areas of system inefficiencies were noted, including, for example,
under utilization of professional scope of practice, an over utilization of
some high-tech diagnostic procedures and pharmaceutical interventions,
and duplication of diagnostic services and administrative services. Also
noted were inappropriate use of emergency departments, clinical time that
is consumed by managerial tasks or excessive paperwork, lack of an
information management system, and inappropriate admissions leading to the
overuse of hospital beds that may be perpetuated by inadequate
community-based supports.
Other areas of inefficiencies included:
- The provision of high cost services that are not supported by required
critical mass;
- Lack of provincial standards to guide accessibility;
- Lack of alternatives for home support and insufficient preventative services;
- Collective agreements that make contracting out and some privatization of
services difficult;
- Long wait times for services that may require hospitalization in the interim;
- Insufficient Board integration and coordination of services;
- High and costly turnover of staff;
- Cost-cutting measures that ultimately result in greater inefficiencies; and,
- Development of services and programs without evidence-based information;
sometimes based upon politicized responses.
Health Human Resources
To recruit and retain health human resources, strategies were identified that
ranged from regional marketing strategies to the need for market determination
of the number of seats in post-secondary education institutions. Expanded access
to education and training programs will be necessary to handle shortages in many
occupations due to an aging workforce. Particular needs exist for psychologists,
pharmacists, occupational therapists, physiotherapists, general practitioners,
nurse practitioners, midwives, speech language pathologists, x-ray
technicians, and home support workers. Better teamwork, improved
communication capacities, and more support for existing staff will
enable a more productive work environment within health boards.
To enable the system to compete more effectively with the private sector,
there was consensus regarding the need for more equitable and competitive
salaries, respectful workplaces that value people and more formal
recognition programs. It was noted that minimizing student debt through
the provision of paid work terms and bursaries are valid recruitment strategies.
There were also opportunities identified for increased shared services and
mobile services, and the resolution of turf issues that hamper
professionals (particularly within the nursing profession) from
practicing to their full scope of practice. Other suggestions
included incentives to recruit and retain provincially-trained medical
graduates and professionals, support for residents who wish to pursue
health careers, increased promotion of the safe lifestyle available in
the province, and reasonable workloads that enable balanced work and
family lives. Workload and other information systems as a basis for
decision-making support are also required.
Other ideas included establishing a corporate culture that promotes
teamwork and best practices, providing opportunities for job
shadowing to encourage a more holistic view of the health care
system, fostering professional development opportunities to assist
professionals in maintaining standards and competencies, and making
computer training mandatory for all health care professionals. It
was noted that there is a need for promotion of the range of health
service career options and opportunities within the school system.
A provincial human resource plan is required - one that takes into
account the configuration of services and programs that will exist
in the province and succession planning to ensure the availability
of skilled professionals.
Accountability
Participants felt accountability can be enhanced through monitoring key
performance indicators such as financial performance, appropriate use
of professional skills, and accessibility and support of wellness
promotion services and programs. Other indicators noted included
reductions in the incidences of high-risk diseases, wait times and
lists, performance on improving outcomes related to the determinants of
health, quality of the work environment, and the strength of collaborative
linkages and partnerships. Standard indicators such as mortality, morbidity,
re-admission rates, utilization rates, and length of hospital stays were also
noted. There was strong support for indicators that concentrate on the
outcomes of treatment and prevention services and for client feedback
and satisfaction surveys.
There is a need to encourage 'no fault, no blame' reporting. Proper
planning and goal setting processes and stronger communication with
respect to the structure, roles and responsibilities of boards is also
needed. Reference was made to the earlier discussion of board structure
including the need for greater public understanding of the role of boards
and individual board members, greater board autonomy and freedom from
political influences commensurate with their accountability, more evidence-based
decision-making and better orientation for board member of their roles and
responsibilities.
Finally, suggestions were offered for helping individuals take more
responsibility for their own health. The public must understand the
cost of health services. Parents, community role models, and health
providers must be encouraged to model healthy practices. Education
is ultimately the key component of helping people assume greater
responsibility for their own health, engaging them in their
understanding of the health system, and encouraging greater
self-responsibility for adopting healthier lifestyles. This
will require more aggressive marketing campaigns and collaborative
efforts to implement the Strategic Social Plan. Methods for reporting
publicly might include public and provider forums, formal mechanisms such as
annual reports, and informal methods that engage community organizations.
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